List any vegetables or fruits you don’t ever want to see ___________________________________

List any other food dislikes ________________________________________________________

List any known food allergies VERY IMPORATANT! _________________________________

Are you currently on a restricted diet? If yes, describe ___________________________________

What diet programs, plans, or products have you tired in the past? __________________________

Do you have any history of the following: heart disease or stroke, diabetes, high blood pressure, high cholesterol, digestive disorder, depression, sleep disorder, cancer, other describe___________________________________________________________________________________________

Have you had surgery within the last year? If yes, what type? _____________________________

Are you pregnant? ____________________________________________________________

Do you exercise? Please describe the types, frequency, and duration________________________

What do you eat on a typically Day?Breakfast__________________________ Lunch ______________________________________Dinner _________________________________ Snacks ________________________________